<html>
<head>
<title>Untitled Document</title>
<style type="text/css">
<!--
.box {
border: 1px solid #000000;
}
.box1 {
border: 3px solid #000000;
}
.t1{
font-family: Verdana, Arial, Helvetica, sans-serif;
font-size: 12px;
font-weight: normal;
color: #000000;
}
</style>
</head>
<body bgcolor="#333333">
<form action="./PatientInsert" method="post">
<P>&nbsp;</P>
<P>&nbsp;</P>
<P>&nbsp;</P>
<table width="477" border="0" align="center" cellpadding="0" cellspacing="0" bgcolor="#99CCCC" class="box1">
<tr>
<td width="475">
<input name="" type="image" src="pinfo.jpg">
</td>
</tr>
<tr>
<td height="300" align="center" bgcolor="#999999">
<table border="0" cellpadding="3" cellspacing="3" bgcolor="#99CCCC" class="box">
<tr>
<td class="t1">PName
</td>
<td>
<input name="pname" type="text" class="box">
</td>
</tr>
<tr>
<td class="t1">
PAddress
</td>
<td>
<input name="paddr" type="text" class="box">
</td>
</tr>
<tr>
<td class="t1">
Diesease
</td>
<td>
<input name="diesease" type="text" class="box">
</td>
</tr>
<tr>
<td class="t1">
Drugs
</td>
<td>
<input name="drugs" type="checkbox" class="box" value="Insulin">
<span class="t1">Insulin</span> <br>
<input name="drugs" type="checkbox" class="box" value="cyllergy">
<span class="t1">cyllergy</span> <br>
<input name="drugs" type="checkbox" class="box" value="penculin">
<span class="t1">penculin</span> <br>
</td>
</tr>
<tr>
<td colspan="2" bgcolor="#FFFFFF" >
<div align="center">
<input src="rb.jpg" type="image" border="0" value="Login" id="submit" name="submit" tabindex="3">
</div></td>
</tr>
<!--
<tr>
<td colspan="2">
<div align="center">
<input type="submit" class="box" value="Register">
<input type="submit" class="box" value="Register">
</div></td>
</tr>
-->
</table></td>
</tr>
</table>
</form>
</body>
</html>